HOSPITALISM. BY GEORGE M. GOULD, A.M., M.D.. OF PHILADELPHIA. FROM THE MEDICAL NEWS, June 22, 1895. [Reprinted from The Medical News, June 22, 1895.] HOSPITALISM} By GEORGE M. GOULD, A.M., M.D., OF PHILADELPHIA. Definition.—The dispensary-disease, or hospitalism, is a contagious, epidemic, ingravescent neurosis of civil- ization, limited (it is to be hoped) as regards time to the present fin de siecle, and as regards geographic distribu- tions to urban populations; it attacks three considerable classes, the professional philanthropist, the commercial physician, and the social sponger, and, so far as medi- cine is concerned, is characterized by a maniacal pro- pensity to professional suicide and to the spread of the disease by the inoculation of the will with the germs of the affection. Etiology.—In brief, there are two chief etiologic fac- tors. The first consists in the morbid desire of the lazy charity-monger to perform his duties vicariously; the second springs from the ambition of certain physicians to “get on, regardless.” From the interactions and mutual complementings of these these two cachexias arises the distinct type of disease called hospitalism. These two agencies may need an added word of explana- tion. The first, the habit of the professional philan- thropist, united to the universal desire to satisfy con- science with vicarious charity, is a widespread evidence of religious and ethical anemia, resulting in multiform 1 A paper read before the American Academy of Medicine, at Baltimore, May 4, 1895. 2 sociologic denutrition and malfunction. The unregen- erate layman, the civilized savage of modern times, is subject to a strange hypnotic delusion that the universal law of the biologic world antedating civilization is an egregious error. This law has up to now proceeded on the assumption that health and vitality are the condi- tions of permitted life, and that this health and vitality are based essentially upon pay or equivalence of ser- vice, upon personal self-dependence, desire, and effort. The modern philanthropist jauntily sets aside the wisdom of the ages, the necessities of evolution, and all that, and says he has a much better idea of how to conduct the universe than has God. Acting upon this antithetic science he says the conditions of social health are the encouragement of personal dependence and the increase of pauperism. His remarkable therapeutic theory is that to cure a disease we must administer a remedy that in health would produce exactly the symptoms of the disease. He therefore seeks to cure pauperism and de- pendence by increasing the number of paupers and dependants. There is nothing so delightful to weak souls as the unctuous self-flattery of benevolence, and there are few things more satisfying than to rid one’s self of a nag- ging duty. We thus have two classes of citizens: The tremendously large class that pay others to perform their personal duties, and the very small class of those that hire themselves out as agents of the first class. Charity and the personal relation to the poor and sick are thus deftly avoided by this copartnership, and alms- giving and institutionalism deceptively act as vicegerents of the genuine officers. This is the first factor of the dispensary-disease. The second factor is confined to the medical profes- sion itself. Like most other people, certain doctors desire to “ get on, regardless.” The vicarious and pro- fessional philanthropist offers him the means in the shape 3 of institutions for the treatment of all other diseases ex- cept the hospitalic variety. (Perhaps in the progress of time and with the growth of virtue we shall have a special hospital in every large city where may be treated those in the acute and violent stages of the terrible disease, Epidemic Hospitalism.) If the enterprising doctor can get himself appointed “ Professor,” or “ visit- ing physician ” to one of the numerous institutions sup- plied by the vicarious philanthropist he will at once become better known ; he will be furnished abundant “ clinical materialhe will get ahead of his less fortu- nate brothers ; and he will assuredly “get on, regardless.” Lachrymose sentimentalism and philanthropic vanity are appealed to, endowments follow, wills and codicils to wills are made, and lo ! there arise the lofty walls, the spacious wards, the waiting-rooms and operating-rooms, the crowded out-patient departments, the boards of wealthy trustees, and the not-to-be-forgotten medical staff itself. Sometimes the physician bound to get on, the busi- ness doctor, sans phrase, conceals his ambition with the broad mantle of institutionalism itself, and it appears that the patient (the doctor-patient afflicted with the dis- ease) indulges in a mild monomania of enthusiasm for his particular medical college, for medical science, and for the purposes of medical instruction. He solemnly contends that without an abundance of clinical material the best medical instruction would be impossible, and medical colleges would languish. His by-standing con- freres, not yet afflicted with the disease, smile pityingly, both at the patient’s delusions and at the sorry belief of the patient that he is deceiving those about him as to the real motives of his mind. Those healthy-minded at- tendants know that there will always be an abundance of clinical material supplied by the worthy, the deserv- ing, and the really poor, without the appeal of competi- tive medical charity to those who could pay for medical 4 service. They also know that nine times out of ten his medical college itself has no ethical or scientific raison d'etre whatever, but is itself simply another bit of objec- tive evidence of personal and selfish ambition on the part of those who are “ getting on, regardless ” by means of their “ Professorships” and the advertisement of offi- cial position. If one has been vouchsafed a clear glance into the inferno of political chicanery and undiluted deviltry that often go on to secure a professorship in a modern medical college, he will have a perfect demon- stration of the altruism and the purity of the “ charity ” at work among the candidates. Men do not smash the entire Decalogue and commit all the venial sins in order to get an opportunity to be kind to the sick or to teach boys how to cure disease. The etiology of hospitalism may, therefore, be epito- mized as consisting, first, in the morbid desire of the well- to-do to rid themselves of real charity and of the duty of personal hand-to-hand and face-to-face kindness, by the self-deceptive, vicarious makeshift of almsgiving ; and, second, to the get-on-regardless physician, reckless of the good of the profession, greedy of office and of patients, even though they are of the non-paying variety. Professorialism is only a variant of the disease of hos- pitalism, not a distinct type of disease. Symptomatology.—The disease afflicts three distinct classes of society, and has a somewhat different symp- tom-complex in each class. i. The first, the endowing class, many of them placed by death beyond the reach of criticism, is composed of those that mistakenly preferred to patch up effects rather than altogether to prevent them, and who left their money without proper stipulation of the conditions under which their trust should be administered. Theirs is a mournful error. There are so many ways, especially in medicine, of preventing disease, of killing the causes of diseases, instead of curing the individualized results, 5 that it is shameful that they did not add wisdom to pity, and to kindness, intellect. If we could but show the benevolent how much greater and more speedily reached would be the effect of their charity if applied to the en- couragement of preventive medicine instead of to cura- tive medicine: One well-equipped and endowed labora- tory of hygiene, of bacteriology, or of sanitary science would do more for humanity than a dozen hospitals. To prevent diphtheria is a million times better than to keep everlastingly treating children ill with diphtheria. But the unwise endower of hospitals committed another intellectual sin—and in this world intellectual error at last and always results in millionfold moral error. He failed to condition his gift with the necessary limitation that as a result of his charity none but the needy and deserving should profit by it. Without that condition, in the mutations of time, his kindness becomes an engine of evil, both to them who receive and to them who ad- minister. The endower is sometimes the State or the city. The fact itself proves that giving to hospitals has so long been recognized as right,per se, that no regard need to be paid as to how the money is spent. It is a most remarkable fact, this of giving away millions of the public money without a single stipulation, and hardly without a demand for accounting. When given to public officers for State asylums and hospitals the precedent is bad enough, but to church, sectarian, and college hospitals, and even to private institutions—this decidedly is to be thought twice about. In the scramble of the competitive medical-charity debauch, the hungry institutions have hit upon a plan of making the universal public a universal endower. Everybody must be made to feel how good he is and to experience the pleasures of almsgiving. We thus have every imaginable form and invention of beggary spurred to the limit of endurance and of impertinence. Hos- 6 pitals Sundays, fairs, ‘‘dances for sweet charity,” masked gambling, and heaven knows what else, are instituted. It might, with self-restrained people, it certainly should, suggest a little prudence to see how prominent in get- ting up and pushing on these things are the wives, mothers-in-law, the personal friends, or the relatives of the ambitious visiting physician, or would-be professor, the advertiser, the newspaper doctor, et hoc genus omne. The motive of self-seeking is too often but poorly, very poorly, concealed, and sometimes it is thought good enough to boast about. 2. The second class, the lay-public, likewise suffers from the disease, although it thinks itself very cunning and lucky in having the disease. There are more dis- eases than hysteria that people love to suffer with, and the dispensary-affection is an example. There is no evil that is more ruinous than the awful one of com- munism. When a man gets that poison in his blood he will be a curse to the world until he is well-hanged, thoroughly dead, and everlastingly buried. There is no curse so fatal as the curse of desiring to get something for nothing. It is the half-hidden rock upon which the very ship of state, democracy itself, is running headlong. Nothing is serving so subtly and so powerfully to pre- vent physical and social health, and to keep the world in the thraldom of disease, as medical beggary and medi- cal communism. When a man buys medical service for nothing he pays a high price for it. He cultivates the habit of lazy reliance on medical aid, and grows careless of hygiene. The people think they are fortunate in being treated for nothing, but instead of curing, the “ treatment” really fastens the disease perpetually upon the very heart of the body politic. The medical profession is bound to the treadmill of curing individual cases and the effects of disease, instead of shutting off the causes of disease. The profession is so hardly pressed and so poorly paid that its members have no time to prevent 7 disease. One of the great curses of medicine is the commercial medical colleges, with the resultant super- abundance of doctors. The hospital and dispensary disease is encouraged by (nay, is one of the direct re- sults of) the commercial medical college, and the vicious circle is completed by the mere reversal of the process. The rivalries and ambitions and “politics” of competi- tive medical charities, displayed every day stark naked to the public, at once arouse and disgust the world, and keep low that standard of professional dignity and honor, so that the profession cannot demand and com- mand health. Hygiene and preventive medicine could at once halve the death-rate if we had the respect of the community, if we but spoke clearly and could carry to realization the known laws of life-saving. If the cunning Communist only got what he thinks he is sponging! But every physician knows well enough he does not get it. How can one man diagnosticate the diseases of a hundred patients with scientific precision and treat them effectively in an hour ? I may not speak dogmatically of other departments of medicine than my own, but I must confess that out of hundreds of cases of hospital refraction work that I have afterward examined in my private office I have never yet seen one, my own included, that was correct. If only the deserving poor were treated, there would not be the crowds; if the phy- sician received even the smallest fee, that fact would make the patient the master instead of the obsequious sponger; and then the doctor’s work would have to be better, or the natural laws of competition would soon set- tle the fate of the bungler, and the “hustler,” and the ‘ cooker ” of hospital statistics. I am not at all certain as to the effect upon the social world of the free treatment of patients with syphilis and gonorrhea and alcoholism—a fact that constitutes a large part of hospital-disease. There are two sides to that question. I am not a little doubtful as to the ethics, and 8 even as to the worldly wisdom of turning the hospital into an annex of the bagnio and the bar-room, a conveni- ence whereby the natural punishment of the infractions of the sexual and hygienic laws (upon which life itself rests) may be escaped. It is not quite certain that we can get the best of God in such ways. There is entirely too much of the “ prophylaxis-of-gonorrhea ” business tainting the whole profession, and literally befouling much hospital-practice. One might more dogmatically decide as to the wisdom of the common social com- mingling of the prostitute and the innocent in the hos- pital-wards and the dispensary waiting-rooms. 3. But the physician is interested in his profession, and the influence of hospitalism upon our guild is be- coming pernicious in the extreme. Take the simple fact of hospital-manners. I well understand that neither the possession of the doctorate degree, nor the possession of the knowledge and skill it should certify, can make a man a gentleman. But there is no doubt that the instant influence of the necessity of treating crowds of mingled deserving poor and of indistinguishable spongers acts disastrously upon the physician’s disposition and man- ners. The very work wherein gentle kindness is as the sunshine’s benediction over the gracious harvest-fields of benevolence is transformed into bitterness and harsh- ness. What is more disgusting than arrogance and dic- tatorialness in a physician F What is more common in hospitals and dispensaries ? A dog judges of his master’s mood by the manner and the timbre of voice, although he understands hardly a word of language proper. Every hospital-patient, likewise, forms quick conclusions as to the man’s character under whose care he comes, and instead of gratitude for the service rendered the ungentlemanly physician is breeding through the com- munity a condition of mind that bodes no good for medi- cine. The patient thinks himself sharp to secure some benefit from grudging surliness, and the overworked, non-paid, half-excusable doctor is glad to get through his job in one or another wretched way. “ He has the European habit and style ”—such is the patient’s verdict. The patients know well enough when they are looked upon as “clinical material,” and when, on the other hand, they are sympathetically treated as unfortunate human beings, whom we have the privilege of helping. And this leads to the thought that nothing so speedily and surely as hospitalism leads to the degeneration of the physician into the therapeutic or pathologic fiend. If an interne or visiting physician hangs about a hospital beyond a certain time, as is well known, the more cer- tainly will he fail as a practising physician. Every day in the hospital teaches him to dissociate disease from humanity, and to fix his attention upon morbidity, per se. He learns to treat disease, and not the diseased human being. The laboratory, necessary as it is, runs the danger of becoming the execution-chamber of prac- tical therapeutics. Every disease must be seen through the lens of personality before it can be thoroughly understood. There is no disease, there are only dis- eased tissues—and the tissues are alive, and there is a living soul unifying all the tissues into that strange pro- duct of life, Homo ; and Homo is not one individual, but includes conditions, family, heredity, age. The rage for “ clinical material ” is becoming a genuine mania, itself a downright disease, a disgrace to curative medicine. Street-car placards and column-long news- paper “ads” soliciting patients are part of the expenses of some hospitals. From a daily paper I clipped the following racy account; it has too much of the air of truth to be more than half-lie : “ A local employment agency has instituted a unique departure. A few days ago ah advertisement appeared in the morning paper, which read : ‘Wanted—A young man suffering from pulmonary or heart disease. Exam- ination free.’ Inquiry at the office of the advertiser 9 10 elicited the information that the ‘ young man ’ was wanted for the various hospitals about town, which were anxious to get live subjects for clinical demonstra- tion. ‘The applicants are received here,’ said the manager of the agency, ‘and are promptly examined. The eligible ones, that is, those who are found to be victims of the two diseases in question, are given cards for presentation at the hospitals which we serve. They are paid well for their services, and they suffer no incon- venience from their experience at the hands of the sur- geons. Sometimes, in fact, they reap benefits which they had not counted on, some of them regaining com- plete health under the treatment. So you see pulmon- ary and heart affections command a sort of premium. Sometimes we find among the applicants some cases even more interesting than we had expected. These men, of course, command more money than the ordi- nary sufferers.’ ” But all these methods of trapping game are often only diversions of the strong, subdominant motive of practice-hunting and success-advertising. Just as the great professors give lectures at medical colleges in order to get consulting practice, so will men consent to bang through a lot of “charity-cases” at the hospital and dispensary in order to have the eclat of the position and the fame that in one way or another brings private practice. Sometimes, indeed, it is not by the indirect means of the fame that patients are secured, but upon one excuse or another—the modus operandi is well known—the hospital is made a very direct feeder of the private office. And what brutal injustice is the indiscriminate treat- ment of hospital-crowds to the younger members of the profession, and to those, the immense majority, who are not of the elect—the poor fellows who are neither pro- fessors, chiefs, nor visiting physicians; it is among the lay poor that the professional poor must work. After years of heroic preparation the young graduate finds the very teachers who have taken his money for instruction 11 treating questionless and gratis those who should be his own pay-patients. I have a profound sympathy for the young and unsuccessful physician. He has been out- rageously deceived, and is daily being outrageously treated by men of his own guild, to whom he has a nat- ural right to turn for aid in this matter. If he settle in the country, the recklessness of the city-hospital and dispensary government pursues him like a fury. The non-discriminating urban physician receives the coun- try patient without question. It is thought that the dis- tance from which the countryman comes cancels all scruples as to duty to one’s colleagues. Medical ethics have at best very narrow geographic limitations.1 Only the countryman’s local physician knows whether he is able to pay or not—but how often is the matter asked by the city brother ? Even in private practice the rights of the distant local physician are but little considered ; how much less, then, are they considered at the dispen- sary ? And thus, to summarize, are we cruelly, consciously, 1 A remedy for the abuse of medical charity is offered by “ A Young Subscriber ’’ in a letter to the Medical Record. He sug- gests that the victim of this abuse “ the next time and whenever he has need of a consultation, or has a patient to send to a specialist, avoid the man who daily robs him by indiscriminate dispensary- work, and pick out instead one who regards the rights of his fel- lows. There are men at the heads of dispensary-classes through- out the city enjoying large special practices, who boast that they have no care for the financial standing of their dispensary-cases so long as they furnish the required material for clinical pur- poses, and as for the complaining doctors they say, ‘let them go and be blanked.’ So long as they can do this and keep the sup- port of the general practitioner, they will hold the same views. The moment they find it affecting their pockets they may at least cease to pride themselves upon their dirty treatment of their pro- fessional brethren. Let the non-dispensary men look to their rights, and they will soon have less wrongs.’’—[Boston Med. and Surg. Journ., March 21, 12 persistently committing professional suicide. Every noodlehead knows that that which costs no thought or labor is not appreciated by men, and yet we tumble over each other in our mad rush to do our grand work for nothing. We make the most valuable thing the most despised by our pusillanimous politics, until the poor public learns, instead of respect, contempt of us. Where is the hospital for free legal advice ? And yet which is the most honored, medicine or the law ? Oh ! for a breath, nay, a blast of professional self-respect that would sweep us into unity. Why should we not have some organization, some esprit de corps ? Even thieves preserve some sort of honor among themselves. Treatment.—Let us briefly consider the treatment of the disease. What can be done to abate this graceless nuisance ? A thousand good hearts and wise minds are racked by this problem. It is almost impos- sible to find a way out. In fact, we have gotten our- selves so pitiably diseased that we can hardly hope for much else than a life of chronic invalidism, at least so far as this generation is concerned. The disease, if one may so speak, is intensely chronic. One thing is cer- tain, we cannot make men moral by act of Congress. There is not one great general remedy. Everyone of us must take the matter up. The Kingdom of Heaven is within you. The influence of one, of each individual, steadily and patiently opposing the wrong will, in time, transform the whole. Every one of us has power ; each one of us has been a sinner; each one may do little or much toward stemming the evil trend. And first as to the endowers, whether individual or communal, let us preach incessantly and repetitively the truth that indiscriminate charity is unadulteratedly sin- ful and cruel. Every penny given without inquiry as to merit is simply hiring people to be sufferers. In a great civilized country, only last year, there was discovered to be a fiendish manufactory of cripples and victims to 13 excite pity and secure alms from the “ charitable.” Children’s eyes were gouged out and every bone in their bodies broken, in order, by their exposure, to stir up the sensibilities of the “ kind hearted,” who, by their gifts, kept the manufactory “ running on full time.” Just as certainly does indiscriminate charity operate now, and here, and everywhere. God’s command is infinitely stern, but it is just as infinitely compassionate, that in the sweat of the brow shall we earn our bread. The lives of East Indian ryots are quite as happy, fully as comfortable, and far more moral than those of an Amer- ican mob of train-wrecking strikers ; and yet the annual income of the ryot is not one-thirtieth of that of the striker. Let it be clearly understood that there is to be no chilling of sympathy, no killing of kindness, no less giving, because of this law of life. There is to be all the more—but the sympathy is to be intellectualized, the kindness is to be made effective, and the giving is really to stop the suffering, and not increase it. We must teach the rich that every endowment of hos- pitals and dispensaries must be conditioned, narrowly, rigidly conditioned, upon the law that only emergency- cases and the absolutely deserving poor are to be treated in hospitals. When importuned to contribute on hos- pital-Sundays, or to attend entertainments, charity-balls, etc., etc., let us refuse, and publicly refuse, unless the managers of such hospitals publicly state that rigid exclu- sion of those able to pay something for medical services is carefully and systematically assured. The indiscriminateness of the doled-out charity of the hospitals is a natural result of the stupid indiscrimination of endowers. These pour out the money, year after year, and century after century, in reckless disregard of the laws of economics, of the real needs of the commu- nity, and of the experiences of other lands. Hospital- farms for epileptics, for the insane, homes for convales- 14 cents, homes for the dying, special hospitals of various kinds, especially for the tuberculous—these and more are pitifully wanted, and yet the old ways and the old evils are stupidly increased. If we could only have an omniscient or even half-wise Czar to direct almsgiving; if it were only someone’s business to instruct people how to give their money. At present it depends either upon haphazard or upon the cunning wiles of some interested person. Rich plebeians, right versed as to oil, or beer, or dry goods, are made presidents or trustees, flattered to the top of their bent with the bauble of office and au- thority in the things of which they haven’t even a spark or a glimpse of knowledge, all in order to wheedle endow- ments out of them. These go on building wings and additions to old evils, until, as with church-building, the historic momentum results in monstrous aggrega- tions of multiform uselessness or abuse. And every day or two the daily newspaper-reporter gets hold of some scandal, a dying patient refused admission to hospitals, a fisticuff of rival visiting physicians, the “politics” of rival hospitals, etc., etc., and regales his readers with it. All the time the evil grows, until one of these fine days the donkey endower will suddenly awaken to a realiza- tion of the fact that he has been imposed upon, and that his ears are several inches longer than they should be. Then he will resign, shut up his pocket-book very tight, and genuine medical chari- ties and properly conducted hospitals will suffer. To arouse the profession to the danger it is incurring by the abuses of medical charity, the danger of a sudden reaction whereby proper medical charity will be stopped, this has been the motive I have had in mind in writings upon this subject during the last six or eight years. It hardly needs the saying that one earnestly desiring the curing of a disease hardly wishes to kill the patient, yet some foolish folk affect to think that those who speak of the disease of the hospitals would destroy all hospitals as 15 incurably diseased. The physician, even of the specialty Hospitalism, hardly desires to become a Reign-of-Terror guillotinist. Nothing is more divinely beautiful than a noble hospital, rightly managed, and illustrating at once the science, the art, and the benevolence of medicine. But, according to the old maxim, corruptiooptimipessima, and a hospital endowed by wealthy hypocrites, managed by medical advertisers, and filled by social parasites, is as bad as the other is good. In the hospitals and dispensaries of England and Wales, 2,855,644 patients were treated in 1878, while in 1893 the number was almost four millions (3,985,263), an increase of noteworthy proportions. At the same time the number of physicians has, of course, also in- creased. In 1882 there was one medical man to 1703 people, whilst in 1893 there was one to every 1427—that is, each medical man has 250 less people in his clientele. If this is true in England, where medical education and medical charity have preserved at least the tradition of sanity, what must it be in the United States ? In order not to be charged with invidiousness, let us take the experience of a foreign institution. I assure you, how- ever, illustrations could be had very much nearer home. St. Thomas’ Hospital, of London, has an annual income of $285,000, and appeals urgently for more money. A writer in the Medical Press and Circular thus further describes the condition of this institution : “ That hospital was chartered by Edward VI, and splendidly endowed with landed estate, and up to the year 1862 it enjoyed a high reputation, and, so far as I know, did its work efficiently. In that year its site at London Bridge was invaded by the Southeastern Rail- way, and the hospital received, I think, $2,300,000 as compensation. That to the common mind would seem to be a tidy sum with which to build a new hospital, especially as the ground which it occupies was secured on the cheapest terms, having just been reclaimed by 16 the Thames embankment, but when architects and builders got, as they did, a firm hold of the job, it turned out to be quite insufficient to realize their aspira- tions. They succeeded in producing not only a heavy deficit, but a veritable white elephant—a building about twice the necessary size, containing bed-accommodation one-third greater than could be maintained by the in- come of the institution, and constructed in every detail in the most expensive manner. It was stated by the royal prince at this meeting that five of the wards are now empty, there being no money to keep them full, but it was not mentioned by his royal highness that several other wards are filled by paying patients, most of wffiom are in no sense deserving of charitable relief, and ought to be in their own houses, nursed and treated at their own expense, and not at the expense of the charitable. “ It would not be just to blame the present adminis- trators of the Hospital for the mad extravagance of their predecessors of thirty years ago, but for the financial administration of the Hospital at the present day they are responsible, and I may ask a question or two on that. I find from Burdett's AtmualihaX. every bed main- tained costs $512.37 per annum, and every patient admit- ted represents an outlay of $38.83, the highest rate among the twenty-three London general hospitals save four. This does not mean that the sick patient costs directly any such sum, for, as far as I can make out from the figures, his maintenance, nursing, and treatment do not consume more than one third of the amount, the re- mainder representing outlay in salaries to officials, pensions, and other matters which are only of indirect benefit, if at all, to the sick patient. When I find that the most efficient provincial, Scotch, and Irish hospi- tals can, and do keep, nurse, and treat a similar patient all told for just half the money, I am moved to ask what claim has St. Thomas’ to public sympathy ? Not all the royal princes, dukes, archbishops, and millionaires in existence will persuade me that a hospital which builds beyond its means, spends its resources like water, and refuses to retrench, deserves to be subsidized with $500,000 or any other sum.” 17 As to the public, every one is a teacher, and may make his voice heard against indiscriminateness. I plainly tell my patients, and the occasion arises nearly every day, that they cannot get as good medical service at the free dispensary as at the private office, and that private treatment is far cheaper than the treatment for which nothing is paid. I think it our duty to stigmatize the hospitals and give them a bad name. We can hardly exaggerate the truth in this respect. Let us laugh to scorn the clap-trap delusion of the masses that at the dispensary they will be treated by the great Professor Bigwig, and that therefore they will be better treated than by yesterday’s graduate, Dr. Nobody. We, of course, know the silliness of such an illusion; we know that often at the hospital Bigwig gets all the honor and young Nobody does all the work Ten to one, with his care and desire to establish a reputation, young Nobody would do the better work of the two, even if Bigwig had the case himself. Then there is the wasted time of the patient, the crowds, the shocking surroundings, the shame of being a pauper ! Let us use the blunt, brutal word, and drive it into their heads—hospitals and dis- pensaries are for paupers ! It will hurt a little, but it will do good. Every older physician has some younger friend and colleague who needs the poor patients and their poor fees. Why not do the patients and the friend a real service with one word of advice ? As to the profession, if one has anything to do with a hospital, one can do not a little in the interest of dis- crimination. A trained mind can learn to detect the old clothes put on for the visit, the odor of whisky, the con- cealment of ability to pay something. There should be no mincing of words with such folk. Every patient caught shamming should be half-insulted and uncere- moniously turned out. Let them go to “ other places where they will be welcomedthe “ other places ” will thereby secure for themselves an evil name in time, which will prove a poor investment. There is one half-evil that is condemned by some and practised by many, but it has the excuse that it is somewhat better than the hospital wholesale business. The drug-store doctor is not, perhaps, the best type of professional man, but he is not so bad as Professor Big- wig. By the drug-store doctor I do not mean the drug- gist who is not an M.D., but who in fact prescribes much as if he were. That problem is fast settling itself by the commercial medical college selling diplomas to the drug- gist. What is meant is the genuine doctor who also keeps a drug-store, but who charges—well, nothing for advice and everything for filling the prescription ! Such a product of our fin de siecle medical civilization is in fact a direct reaction and result of indiscriminate medi- cal charity. And since the doctor gets something, how- ever roundabout, for his work, I am not inclined to scold him much. When hospitalism is whipped out of the field it will be time enough for all good men to turn in and run out the drug store doctor. Still another form the reaction has taken is that illus- trated by the physician who, while pursuing essentially he same plan as the drug-store doctor, carries it out by the vice versa method. I mean the charging for advice but giving the medicine gratis. This is certainly a step, nay, two steps, in advance, and hifs two heads well-de- served and good-resounding whacks with a single shil- lalah. Who does this at once “ gets even” with the soulless hospital and with the nostrum-selling, prescrib- ing druggist, both having tough skulls that need many downright doughty thwacks! Perhaps the same club may in time split wide open another cranium, that of the patent-medicine man. The remarkable progress in the arts of modern pharmacology make possible, and many other reasons make justifiable, the dispensing of one’s own medicines. 19 In England medical clubs are already deemed un- mitigated nuisances and deplorable grievances. With us they have not yet become so, but we are fast enter- ing the same smooth descensus averni. But it seems to me even this phase of the wholesale medical business is preferable to hospitalism—a road, that if not to avernus, trends toward a lake into which certain tormented swine did once rush somewhat hastily, with much relief to their mental disease. One finally asks why should each physician not have his own private dispensary ? Behold his empty office and his unoccupied time ! Why should he deimperson- alize his charitable work and give himself namelessly to an institution—a sort of a corporation which proverbially has neither a body to be abused nor a soul to be saved ? Better it seems to me, and far better, would it b? to do the service and get the gratitude one’s self. In such cases there is a real and a scientific service on the physician’s part, and a real and not a sham gratitude on the part of the patient. Private individuals should go into private competition with the hospitals. The hospitals can be whipped out every time. And when one corrects the botch-work of the hospitals, the time and the health of the patient have been so patently spared that the thank- offering of an unexpected and shyly given fee is much larger than one would have thought of receiving from a “charity-case.” One may perhaps hear the sneer that it would be unprofessional for a hungering young doctor to solicit gratis-cases at his private office—and ten-to-one the sneer would come from one who hangs his name on big sign-boards from his dispensary-doors, and adver- tises himself or his hospital in cheap newspapers and on theater bulletin-boards. I would be far from justifying advertising ways on the part of the younger man, but decidedly when the advertisement of the hospital means the advertisement of the men running the hospital, then I excuse the young non-hospital advertiser first and 20 quickest. When Bigwig quits the trickery, young No- body will soon do so also. I would like to add a suggestion that seems never to have occurred, either to our profession or to its most excellent co-working sister, that of the trained nurse. Thousands of women have heroically and successfully struggled under the greatest difficulties to secure their special training and ability. Thousands more are pre- paring, but already the profession is overcrowded. Why should they not take up the hospital-business as a work for which every consideration of natural and acquired fitness shows them adapted ? The hospital-business is a sort of a special boarding-house business. I see no reason why in America we should drift into the huge barracks-hospital system with droves of daily thousands. The individualization of cases is the first requisite of clinical wisdom, and the individualization of hospitals is another professional desideratum. There might be hun- dreds of single-house hospitals or homes for the sick, adapted to different diseases, and to all purses, in all of our cities, in which nurses should be the responsible owners or controllers, and which any physician might upon regular business-arrangements send his patients, and relieve himself of all except the medical responsi- bilities, the nurse as now carrying out his orders. There is something belittling—I will not use a harsher word— in the custom of physicians going into the boarding- house business—euphuistically called the private hos- pital or the private sanitarium. The physician should not be interested in or bothered by the chambermaid’s work, the price of beef, or the rental of rooms. This is all alien to his proper work, not seldom inimical to it, and even leading sometimes to scandalous conditions. But placed in the hands of a woman specially edu- cated for exactly that sort of thing, it would at once elevate the dignity of her own nurse’s profession, lessen the shame of the impertinent and bulimic hos- 21 pital, and regulate and systematize the physicians’ pro- per labor. But when all has been said and done the hospital- abuse will continue unless professional sentiment is aroused. Trustees, professional philanthropists, and the public will gladly continue to eat the oyster of medical service, and leave the shells to our asinarian rivalries. Possibly there will be no great and thorough cure of the evil so long as we remain a divided profession, so long as local medical societies never touch professional abuses and wrongs, so long as censors have no moral sense and are never incensed not so long as the American Medical Association numbers as members but one in a hundred American medical men. As certainly also there will be no reform while like a lot of unspanked school- boys the members of that Association hanker after and quarrel over the right to advertise nostrums and to asso- ciate with quacks, and while the cynical wrap themselves in the cloak of respectability, hold themselves aloof, and grin sardonically from the safe retreats of success. The two immediate and demanded conditions of all re- form are: 1. That medical men shall have a large share in the government of hospitals, thus making them responsible for abuses and rendering it possible to stop this old mon- key trick of getting chestnuts by our stupid professional paws thrust into the fire. 2. The principle of the Charity-organization Society must be made a part of all hospital-management. It would be well if a genuine copartnership could be re- alized between the local Charity-organization Society and every hospital. At least, there must be at every hospital an officer whose sole duty it shall be to dis- criminate between the worthy and unworthy—and he must be made to discriminate, too. 22 Postscript.—From the Lancet of June 8, 1895, we learn that during the year 1894 there were treated gratui- tously in the London hospitals : General Hospitals: In-patients ...... 52,080 In Convalescent Homes .... 5.585 Accidents and Emergencies . . . 264,379 Out-patients, number of visits . . 1,684,448 Special Hospitals: In-patients 24,963 In Convalescent Homes .... 2,526 Accidents and Emergencies . . . 25,660 Out-patients (visits) .... 1,205,688 Cottage Hospitals and Convalescent Homes : In-patients 24,963 In Convalescent Homes .... 39 Accidents and Emergencies . . . 244 Out-patients (visits) 13,858 Dispensaries : Out-patients ..... 1,204,045 Totals . . . 4,508,478 The Lancet, in pitifully begging for more funds to carry on this tremendous labor, notes that whereas in 1890 the total number of out-patient visits was 2,429,219, in 1894 the number has risen to the perfectly absurd figures of 4,108,039. What more convincing argument could be adduced for lessening the amount of subscriptions, and thus, perhaps, stopping this riotous debauchery of both profession and public ? The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American yournal OF THE Medical Sciences. Established in 1820. A MONTHL YMEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7.so PER ANNUM. LEA BROTHERS dr* CO. PHILADELPHIA.